Today we are digging into something I've said probably way too often: Collaboration is the next breakthrough innovation. And I'm doubling down on this because in the current healthcare landscape, two parties that actually should be talking—like burning up the phone wires talking—are sitting on opposite ends of a very long, very crowded roadway.
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On one end of the road, you have self-insured employers, the ultimate purchasers, plan sponsors. On the other end of the road, the specialists who actually provide the care. Status quo in the middle. We got a whole lot of traffic, let's not forget. We're talking carriers. We got ASOs (administrative services only), TPAs (third-party administrators). We got large, consolidated health system organizations, also in the middle there, often with their own interests.
It is no wonder one of my guests today, Leo Spector, MD, MBA, he says these two groups—the plan sponsors and the specialists—are often like two ships passing in the night.
So, today we are talking about bridging that gap, bringing the two ends of the road together, putting a gang plank betwixt the ships. We have lots of metaphors.
And to have this conversation about bridging this gap, I have with me today Adam Stavisky, who has managed benefits for Walmart among other massive member populations; and he now consults with innovative purchasers.
We have Dr. Leo Spector, a surgeon and CEO of OrthoCarolina.
And we also have Ryan Wells, who is the founder and CEO of Health Here, which is an organization that provides the digital bridge to make sure that any direct connections don't result in an inadvertent additional pile of manual paperwork and administrative waste—because the current rails of healthcare don't really support direct contracting so well.
Okay … so, this is how this conversation that follows is gonna go down. First, we dig into the complications, let's call them, when the two ends of the road start to talk to each other, right? We should be educating ourselves in the topics that we know for a fact are gonna come up that we do not want to turn into a dustup.
So, let's prep for these in advance. Here are the things that we know are going to rear up whenever you get specialists and plan sponsors in a room.
Here's the first one. What is quality? Who delivers quality? What is appropriate care? What is care that is of value? Right? So, we spend some time on this one because we've all been there.
As we were talking about this one, though, I wanna point out Adam Stavisky, he made a beautiful point when we were level setting what is the opportunity here really as far as quality and appropriateness is concerned. In other words, what is the why to even try to figure this out.
This is what he said. He said, "Traditional carrier networks have a tough time in any really informed quality conversation because they're often trapped by 'disruption analyses.'"
If you have any given plan sponsor who insists that every single doctor remains in network to avoid the dreaded D word (disruption), then that plan sponsor is de facto prioritizing no disruption over patient quality and even patient safety. Because you wind up with clinicians who are practicing medicine standards of deviation differently from the best practice, and they wind up in everybody's network.
But look, that challenge is actually the opportunity because when you get the ultimate purchasers and those delivering the actual care sitting around a table together, this is why collaboration is the breakthrough innovation because you can put your heads together and work it out.
I mean, progress might be iterative; but if you don't try, then you'll be left with the status quo—these lazy networks where quality and price in the same network is highly variable. And I'll leave it at that.
Next area of contention that always comes up is, how does one scale this? Most plan sponsor teams actually have a day job, and that day job is not doing a national road trip negotiating direct contracts in every geography. So, we talk about this at some length. And buckle up—Ryan Wells has some insights.
And then our last complication that we talk about today that will, for sure, arise during any attempt to tesseract the beginning and the end of the road together is, any smart specialist thinking about spending time and money to rejigger their practice and their data and their contracts will immediately ask, "How are you, plan sponsor, incentivizing members to come to my practice? Because I'm not gonna do all this and then get crickets," which is something that John Rodis, MD, MBA (EP286); Steve Schutzer, MD (EP294); and others have talked about happening. You level up quality and safety, and no one cares.
When I interviewed Mark Fendrick, MD (EP308), he called benefit design and payment design "peanut butter and jelly." You gotta have both for this to work well. So, we talk about that for a bit.
Okay … so, after we explore each of these three complications, we then talk about what's the roadmap here? Where are we, and what does the future look like? And in sum, you could put this whole thing under the banner of "What do our Center of Excellence models look like?"
If you think about—and I hadn't, so this was a revelation for me—but if you think about what does direct contracting look like at scale, this is where you're gonna wind up: in some kind of Center of Excellence model.
We now have options that include what Ryan Wells calls Center of Excellence 1.0, which is pretty much the fly to a brand-name hospital model, mostly. And look, just to quantify the why here, even for this 1.0 version, I literally moments ago just saw a post from Jonathan Baran talking about sending one of their plan members to Baltimore from Wisconsin for heart surgery.
He wrote, "One Madison hospital charges $219,000 for a surgery that Johns Hopkins—one of the best cardiac programs on earth—does for $80K door to door."
Also in the market at this time, we have Center of Excellence Model 2.0, which, by my accounting, is a more scaled availability in local markets. But the thing is, even 2.0 uses a lot of the status quo rails that were designed for fee for service and requires a lot of manual labor on the side because half the stuff that you're trying to track when you're doing direct contracting, the existing rails don't support it. You're gonna have to have a whole side hustle, separate operation going on to just, like, adjudicate or reconcile most of the risk-based anything.
So, yeah … we finish up this conversation getting both sides of our road here talking about Center of Excellence 3.0, where the rails are different. Maybe we compress the road, actually, and these metaphors completely fall apart, which would be kind of great, actually.
And in this 3.0 complication, Ryan Wells has definite thoughts because his company, Health Here, works with clinical organizations across the country to stand up these payment and communication pathways. But bottom line, it is time to stop with a game of telephone and really start talking directly.
This podcast is sponsored by Aventria Health Group, and today we did have an assist. I need to thank Health Here, who donated some financial support to defray the costs of this episode today.
So, thank you so much to Health Here for your generosity.
Also mentioned in this episode are Health Here; OrthoCarolina; John Rodis, MD, MBA; Steve Schutzer, MD; Mark Fendrick, MD; Jonathan Baran; Aventria Health Group; The OrthoForum; OrthoForum Value Network; Karen Simonton; Ivana Krajcinovic, PhD; Jacob Asher, MD; Mark Cuban; and Cost Plus Drugs.
For a list of healthcare industry acronyms and terms that may be unfamiliar to you, click here.
You can learn more at healthhere.com and by connecting with Ryan, Dr. Spector, and Adam on LinkedIn.
Ryan Wells is the founder and CEO of Health Here, where he brings 30 years of experience advancing healthcare technology and payment innovation. Health Here enables specialty practices to succeed in value-based care through fintech-enabled episodic payment models.
The company's Clinic Q Suite integrates intake, estimates, payments, and outcomes tracking. Its Qūb platform allows specialists to contract and scale episodic payment programs, including commercial and direct-to-employer arrangements. Today, Health Here supports more than 1300 providers across 150 care sites, serving over 12 million musculoskeletal patients nationwide.
Leo R. Spector, MD, MBA, a board-certified fellowship-trained orthopedic spine surgeon, has enjoyed a 19-year tenure with OrthoCarolina, holding multiple leadership positions, including chief quality officer, member of the executive committee, chairman of the quality/value committee, and co-fellowship director at the OrthoCarolina Spine Center.
He has been serving as the CEO of OrthoCarolina since 2024. Dr. Spector continues to practice while active as the OrthoCarolina CEO.
Adam Stavisky serves on the board of directors for Omada Health and advises company founders on product, partner, and go-to-market strategies. Previously, he was the SVP of U.S. Benefits for Walmart, where he was responsible for Walmart's strategic vision and delivery of all benefits across its U.S. businesses. During his tenure, Stavisky championed multiple innovations that markedly improved the health and financial security for its 1.6 million U.S. associates.
00:00 Introduction.
00:32 Collaboration as the next breakthrough innovation.
02:24 A summary of the upcoming conversation.
05:45 A summary of where we are and what the future looks like.
06:24 A relevant post from Jonathan Baran.
08:12 The conversation with Ryan Wells, Dr. Leo Spector, and Adam Stavisky: collaboration from the standpoint of a specialist.
12:22 The pitfalls of data accuracy and defining what quality means from the POV of a self-insured employer.
15:36 Defining quality and data accuracy from the POV of a physician.
15:57 How do you measure outcomes when assessing quality and looking at the available data?
21:45 EP294 with Steve Schutzer, MD.
22:06 Scale and operationalization: How do we do it?
27:00 Shout-out to OrthoForum.
29:58 Take Two: EP398 with Jacob Asher, MD.
30:13 EP501 with Ivana Krajcinovic, PhD.
30:30 How things could be better.
33:29 One last complication and how to structure benefit design to align incentives.
35:33 What an "anti-cricket" program looks like.
37:24 EP308 with Mark Fendrick, MD.
37:34 How do we operationalize benefit design and aligned incentives?
39:39 What we're seeing today in Centers of Excellence 2.0.
41:47 What Adam wants to make clear in all of this.
Recent past interviews:
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Brian Machut, Ivana Krajcinovic, Dr Jacob Asher (Take Two: EP398), Stacey Richter (EP500), Dr Jay Kimmel, Mark Noel, Gary Campbell (Take Two: EP341), Zack Kanter